Sexual Medicine: Principles and Practice

140 Pages·2018·1.832 MB·English

by  Gunasekaran, Karthik, Khan, Shah Dupesh

Sexual Medicine
Principles and Practice
Karthik Gunasekaran
Shah Dupesh Khan
Editors
123
Sexual Medicine
Karthik Gunasekaran • Shah Dupesh Khan
Editors
Sexual Medicine
Principles and Practice
Editors
Karthik Gunasekaran Shah Dupesh Khan
The Metromale Clinic and Fertility Center The Metromale Clinic and Fertility Center
Chennai Chennai
India India
ISBN 978-981-13-1225-0 ISBN 978-981-13-1226-7 (eBook)
https://doi.org/10.1007/978-981-13-1226-7
Library of Congress Control Number: 2018954051
© Springer Nature Singapore Pte Ltd. 2019
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Foreword
Reproduction is the law of life. We all live to reproduce and continue to live through
our offspring. Species that are able to reproduce successfully grow and thrive.
Others decline and disappear.
Sex is the driving force that keeps reproduction going. Sex seems to be the only
way for the large majority of people to reproduce. The advent of assisted reproduc-
tion and the newer reproductive technologies would hardly make any change in the
reproductive lives of most of the people. They may have to and will continue to
reproduce in the old fashion way—sexual intercourse-related reproduction.
Sexual problems are rampant and are almost universal. They occur with equal
frequencies in both men and women. As men are expected to perform, it is often felt
that sexual problems are more prevalent in men. However, sexual problems in
women occur with equal frequency but are often untold and often go unnoticed.
Bedroom tragedies are often worse than boardroom tragedies and often lead to
problems in both the fronts.
Sexual medicine is an uncharted territory. There are very few qualified, trained,
or self-trained practitioners of sexual medicine. The field is often dominated by
sexual medicine charlatans and mavericks who continue to sell wrong ideas to peo-
ple, such as “masturbation is harmful” and many other sexual myths.
Medical education in India and in many other countries is bereft of formal or
informal training in sexual medicine at all levels. This has not helped the situation
improve any further. Neither the gynecologist who is often the primary physician
for the woman, nor the urologist who may be the primary physician for men, nor the
general practitioner or the family physician enquires about the sexual health of their
clients.
Men and women are sexual beings with varying sexual needs from puberty to,
often, the grave. This need varies in different phases of life in both sexes. A proper
history taking in all adolescents, adults, and elderly patients requires proper
knowledge.
This book edited by two eminent andrologists with contributions from experts in
sexual medicine from India and abroad attempts to fulfill the lacunae in sexual med-
icine education. The chapters cover a wide range of topics written by practitioners
of sexual medicine, intended for general practitioners and early career gynecolo-
gists, urologists, andrologists, and sexual medicine specialists. The chapters include
v
vi Foreword
physiology of sexual response, importance of history taking, and sexual dysfunction
in men and women and in the young and not so young.
The book, however, does not address sex during pregnancy, sex in the postpar-
tum period, and sex in special situations. I am sure the next edition of the book will
address these issues. This concise book I hope would find a place in the library of
all practitioners of gynecology, urology, andrology, and family medicine.
Chennai, India Pandiyan Natarajan
Contents
1 The Human Sexual Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Shah Dupesh Khan and Karthik Gunasekaran
2 How to Take a Sexual History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Narayana Reddy and Shah Dupesh Khan
3 Erectile Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Karthik Gunasekaran and Shah Dupesh Khan
4 Ejaculatory Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Pandiyan Natarajan and Shah Dupesh Khan
5 Sexual Dysfunction and Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Pandiyan Natarajan and Shah Dupesh Khan
6 Female Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Manu Lakshmi and Shah Dupesh Khan
7 Sexual Pain Disorders in Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Manu Lakshmi and Shah Dupesh Khan
8 Testosterone Replacement Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
G. Rastrelli, Y. Reisman, S. Ferri, O. Prontera,
A. Sforza, M. Maggi, and G. Corona
9 Psychotherapy for Sexual Dysfunctions . . . . . . . . . . . . . . . . . . . . . . . . 95
A. Sathyanarayana Reddy
10 Micropenis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Karthik Gunasekaran and Shah Dupesh Khan
11 Sexual Paraphilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Shah Dupesh Khan and Karthik Gunasekaran
12 Sexual Health in the Aging Couple . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Prashanth Baspure
vii
About the Editors
Karthik  Gunasekaran, MS, FRCS (Glasgow), FECSM is an andrologist,

embryologist, and sexual medicine specialist. Dr. Karthik graduated from Madras
Medical College and completed his master’s in surgery there. During this time, he
was awarded the Prof. Venugopal gold medal in urology. He completed his fellow-
ship in pelvic surgery at the Cleveland Clinic Foundation, USA. His andrology and
embryology training were from Chettinad University, Chennai. He completed the
ESSM course in Hungary and secured the FECSM in 2014, prior to obtaining his
FRCS from the Royal College of Physicians and Surgeons of Glasgow. He has been
serving as Lead Andrologist and Reproductive Microsurgeon at Metromale Clinic
and Fertility Center since 2013.
Shah Dupesh Khan, MBBS, DCE, FASM, (PhD) is the Lead Consultant for

Andrology and Sexual Medicine at the Metromale Clinic and Fertility Center. He
graduated from Chengalpattu Government Medical College and finished his post-
graduation in embryology, which he passed with honors. He then pursued his fel-
lowship in andrology and sexual medicine at the Department of Reproductive
Medicine, Chettinad Health City, completing it with double honors. He also received
the Rajah Muthiah award for his academic achievements. He has filed for a patent
on human sperm lyophilization and was shortlisted for the 2014 Medical Healthcare
Innovation award in recognition of his contributions. Dr. Shah has presented four
prize-winning papers at the ISAR (Indian Society of Assisted Reproduction) and
Chettinad International Fertility colloquiums. He has eight publications and one
textbook on Male Infertility to his credit and is currently investigating stem cells
and cryobiology.
ix
The Human Sexual Response 1
Shah Dupesh Khan and Karthik Gunasekaran
Introduction
Sex remains highly controversial and is a major driving force for the human brain
[1]. The brain is the master seat control for all sexual behaviour. Human beings are
sexual through a better part of their entire lives [1]. Sexuality of humans manifests
in different ways with increasing age. Despite the controversies that surround
human sex, for a majority of us, sex is a highly pleasurable process [2]. In the
boarder context things, good sexual health definitely goes hand in hand with general
wellness and good health [2]. But why engage in sex in the first place? Sex is defi-
nitely more wasteful compared to asexual modalities of reproduction [3]. Moreover
sex and sexual reproduction are far less efficient in propagating a species as com-
pared to asexual reproduction [3]. The exact answer however has eluded researchers
for years despite excellent studies on animal sexual behaviour.
Human beings seem to engage in sex for a variety of reasons. In a study by
Meston and Buss, that involved over 1500 young men and women, a total of 237
unique reasons were found that motivated participants to engage in sexual activity
[4, 5]. The reasons could be broadly categorized as physical needs, emotional,
attainment of a goal and lastly insecurity. Emotional reasons were love and/or com-
mitment along with the need to express it. Physical reasons included pleasure seek-
ing and fulfilment [4, 5]. Goals included resources, status and even revenge.
Insecurity included ‘guarding the mate’ and fulfilling a sense of duty. Emotional
reasons predominated over all other reasons for partnered sex, closely followed by
physical needs [4, 5].
S. D. Khan · K. Gunasekaran, MS, FRCS (Glasgow), FECSM (*)
The Metromale Clinic and Fertility Center,
No 1, Crescent Park Street, T-Nagar, Chennai, India
© Springer Nature Singapore Pte Ltd. 2019 1
K. Gunasekaran, S. D. Khan (eds.), Sexual Medicine,
https://doi.org/10.1007/978-981-13-1226-7_1
2 S. D. Khan and K. Gunasekaran
Human Sexual Behaviour and Culture
Sexual behaviour definitely plays an important role in species survival, yet it is
highly influenced by an individual’s society and cultural context of the individual’s
upbringing. Unlike other species where sexual behaviour is adaptive, higher brain
functions like ‘morality’ constantly affect sexual behaviour [6]. Across cultures
and societies in different parts of the world, human sex is not always tailored
towards reproduction as compared to other animals [7]. Human sex and biological
reproduction share a complex yet intricate relationship that is non-linear [6, 7].
Sexual behaviour is intensely social and is influenced by culture, biology and/or
one’s own fantasies and/or beliefs. Sexual behaviour also changes through the
years depending on the individual’s health, social interaction and choice of part-
ners. Sex is influenced by an individual’s social boundaries along the frameworks
of his or her past sexual experience. A good example would be the shame felt by a
woman when she is sexually abused [8]. This shame and guilt are strongly linked
to the individual’s sexuality and can affect the person’s current and/or future sexual
relationship throughout her sex life. Clearly, there are multiple routes to human
sexual response and multiple cues to which human beings can sexually respond.
Sex and social behaviour share a tangible link [9]. Understanding and responding
to both sexual and non-sexual cues in day-to-day species interaction and watching
porn and getting aroused suggest the presence of ‘sexual mirror neurons’ in the
human brain. Although not directly proven, same regions of the brain are shown to
fire while ‘doing’ as well as ‘observing’ the act [10–13]. The functionality of this
neural network definitely varies among individuals and this variance also decides
the individual’s sexual susceptibility to sexual stimuli, for example watching por-
nography [12, 13].
The development of sexual response in the context of social interaction starts as
early as the infant–parent relationship [14]. Male infants get erections and female
infants lubricate as early as 24 h after birth. Infants are frequently found fondling
their genitals and also showing curiosity in the genitals of adults and other infants
[14]. With increasing age and brain development, the child learns to recognize the
erotic nature of sexual interactions. Puberty and release of gonadal hormones play a
cardinal role in this aspect. The complexity of sex is best viewed in terms of brain
development both functionally and morphologically in terms of size with respect to
human development and/or evolution [15].
Pitfalls of the Masters and Johnson’s Model of Human
Sexual Response
Masters and Johnson introduced the four-stage cycle of the human sexual response
(HSRC) to describe the physiological sequence of changes that they observed dur-
ing lab-performed sexual activities of coitus and masturbation [16]. One of the big-
gest pitfalls of the model was that it omitted the concept of sexual drive which was
well emphasized in the much simpler two-phase model of sexual response proposed